Explaining medical staff services to non-MSPs

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Editor's note: The following is an excerpt from Magee Rehabilitation Hospital's newsletter, which explains the importance of medical staff services. The writeup is in honor of Medical Staff Services Awareness Week.

The primary purpose of the medical staff is to provide oversight for the quality of care, treatment, and services to our patients at Magee Rehabilitation Center. It is a self-governing body that is charged with overseeing that quality care is delivered. One of the ways it successfully does this is through the process of credentialing and recredentialing, which is performed by MSPs. These individuals obtain, verify, and assess the qualifications of a licensed independent practitioner (at a minimum, they are: physicians, dentists, podiatrists, advanced practice nurses) as a basis for helping the medical staff make a decision and then offer a recommendation to the Board of Trustees for final decision on whether a practitioner should be granted privileges and/or have an appointment to membership on the medical staff.

The work of MSPs is done for the following reasons:

1. Patient safety, which is the number one goal at Magee. Only those providers who meet high standards to treat patients can deliver care.
2. Hospital liability. If credentialing is not performed, the hospital is liable for any patient harm caused by a substandard clinician.
3. Compliance with The Joint Commission (accreditation standards) and regulatory agencies (state/federal) requirements as well as hospital policies. For example, in order to participate in Medicare, Medicaid, and other federal and state healthcare programs, Magee must meet the Centers for Medicare and Medicaid Conditions of Participation requirements, which stipulate that providers must be credentialed in order for the organization to be accredited to receive payment from Medicare/Medicaid programs.

MSPs work with various staff, who are involved in a series of medical staff activities to help achieve quality patient care. Here is a snippet of some of those functions. In the accompanying photo are (from left to right, back row to front row):

• Carol Vinci, director of risk management/patient safety officer, is responsible for mitigating any and all risks to Magee. She works with MSPs to ensure that each practitioner has the state required amount of malpractice insurance.
• Jack Carroll, president and CEO, is also a board member and legally responsible for the conduct of the hospital as an institution.
• Guy Fried, MD, chief medical officer, is also a board member and responsible for the clinical oversight of care provided by practitioners with privileges. As board members, they decide on the granting of clinical privileges.
• Julie Psenicka, executive assistant to Dr. Fried and a MSP, performs a monthly background check on each credentialed practitioner to ensure they are not on the Office of Inspector General’s exclusions lists. If they are, it means that they are excluded from Medicare/Medicaid and other federal programs and Magee would not be able to bill for those services the excluded practitioner provided.
• Venus Bradley, senior manager, medical staff services, manages and conducts the verification process through primary source sites of the provider’s education, training, experience, malpractice insurance, professional license, and health. She is also responsible for ensuring compliance with hospital policies, accreditation and regulatory standards and collaborating with medical staff leadership and other key staff on issues of concern related to an applicant’s credentials file and/or matters that affect a practitioner’s clinical privileges.
• George Harrell, a patient and a key reason why credentialing is performed
• Jeanne Doherty, MD, assistant medical director, is responsible for data collection extracted from FPPE and OPPE of credentialed practitioners. FPPE and OPPE provide performance information that is used to determine whether a practitioner’s privileges will be renewed.

The work conducted by MSPs on an individual basis is essential to the Hospital in achieving its goal of delivering quality patient care. However, it is the collective work performed by all of us named above that make us the gatekeepers of patient safety and quality services!